Emergency Department: Management of Radiation Exposed/Contaminated Patients CAUTION This presentation, "Emergency Department: Management of Radiation Exposed/Contaminated Patients,вЂќ was prepared as a public service by the Health Physics Society for hospital staff training. The presentation includes talking points on the Notes pages, which can be viewed if you go to the File Menu and "Save As" a PowerPoint file to your computer. The talking points are provided with each slide to assist the presenter in answering questions. It is not expected that all the information in the talking points will be presented during the training. The presentation can be edited to fit the needs of the user. The authors request that that appropriate attribution be given for this material and would like to know who is presenting it and to what groups. That information and comments may be sent to Jerrold T. Bushberg, PhD, UC Davis Health System, at email@example.com. Protecting Staff from Contamination вЂў Follow universal precautions. вЂў Survey hands and clothing with a radiation meter. вЂў Replace contaminated gloves or clothing. вЂў Keep the work area free of contamination. Key Points вЂў вЂў Contamination is easy to detect and most of it can be removed. It is very unlikely that medical staff will receive large radiation doses from treating contaminated patients. Reducing Radiation Exposure Time Minimize time spent near radiation sources. To Limit Caregiver Dose to 5 rem Distance Maintain maximal practical distance from radiation source. Distance Rate Stay time 1 ft 12.5 R/hr 24 min 2 ft 3.1 R/hr 1.6 hr 5 ft 0.5 R/hr 10 hr 8 ft 0.2 R/hr 25 hr Shielding Place radioactive sources in a lead container. Detecting and Measuring Radiation пЃ® Instruments пЃ± пЃ± пЃ® Locate contamination - GM Survey Meter (Geiger counter) Measure exposure rate - Ion Chamber Personal Dosimeters - Measure doses to staff пЃ± пЃ± Radiation Badge - Film/TLD Self-reading dosimeter (analog and digital) Patient Management - Priorities Triage пЃ® пЃ® пЃ® Medical triage is the highest priority. Radiation exposure and contamination are secondary considerations. Degree of decontamination is dictated by number of and capacity to treat other injured patients. Patient Management - Triage Triage based on: пЃ® пЃ® пЃ® пЃ® Injuries Signs and symptoms - nausea, vomiting, fatigue, diarrhea History - Where were you when the incident occurred, i.e. how far from the actual event site? Contamination survey Contamination Surveys пЃ® пЃ® пЃ® пЃ® Survey with GM survey meters. Those familiar with the use of radiation detection instruments should operate them. Goal is <5 times background. Prepare protocol for survey and documentation. photo credits: REAC/TS вЂў Hold probe ~1/2 inch from surface. вЂў Move at a rate of 1 to 2 inches per second. вЂў Follow logical pattern. вЂў Document readings in counts per minute (cpm) . Directions пЃ® Clear directions (in appropriate languages) are necessary to help individuals understand what is expected of them. Surveying After Each Decontamination пЃ® Provisions must be provided for repeat surveying of individuals after each decontamination procedure to determine success of efforts and when individuals can be routed out of the decontamination center. photo credits: REAC/TS Mass Decontamination Facilities пЃ® пЃ® Where possible, the decontamination of many contaminated individuals should be carried out in existing shower facilities (e.g., at a fire house, school locker room, or public campground). When such facilities are not immediately available, field decontamination capabilities may have to be implemented. Mass Decontamination Mass Decontamination пЃ® Runoff пЃ± пЃ® Responders should closely monitor the direction of runoff to prevent cross contamination between lanes and between zones. If possible, the decontamination area should contain a storm water drain or be on a slope that allows control of water runoff. EPA and Runoff пЃ± пЃ± The Environmental Protection Agency has stated that it will not hold responders liable for runoff in a chemical or biological incident caused by a terrorist event. (EPA letter dated 17 September 2000) Protection of human life and health is primary goal. Second-Stage Decontamination Ambulatory Patients пЃ® When surveying shows that preliminary decontamination of individuals has not been complete, they should be sent to a secondstage decontamination facility (e.g., specialized decontamination tent). Second-Stage Decontamination Nonambulatory Patients пЃ® Some specialized decontamination tents permit capabilities for decontamination of nonambulatory patients as well as those who can walk. Clothing for Decontaminated Individuals пЃ® пЃ® Supplies of clean clothing (sheets, blankets, scrub suits, etc.) should be available for individuals exiting decontamination stations. Provide plastic bags for personal items, wallets, jewelry. Gowning Capabilities пЃ® Patients exiting second-stage decontamination facilities need to be provided with clean clothes (hospital gowns, coveralls, sheets or blankets). Resurveying пЃ® Individuals exiting the secondstage decontamination facility should be surveyed again to determine the effectiveness of decontamination. Individuals found to still be contaminated can be rerouted through the secondstage decontamination effort. Patient Management - Decontamination пЃ® пЃ® пЃ® пЃ® Carefully remove and bag patientвЂ™s clothing and personal belongings (typically removes 95 percent of contamination). Survey patient and, if practical, collect samples. Handle foreign objects with care until proven nonradioactive with survey meter. Decontamination priorities: пЃ± пЃ± Decontaminate wounds first, then intact skin. Start with highest levels of contamination. пЃ® Change outer gloves frequently to minimize spread of contamination. пЃ® Protect uncontaminated wounds with waterproof dressings. Patient Management - Decontamination пЃ® Contaminated wounds: пЃ± пЃ± пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® Irrigate and gently scrub with surgical sponge. Extend wound debridement for removal of contamination only in extreme cases and upon expert advice. Avoid overly aggressive decontamination. Change dressings frequently. Decontaminate intact skin and hair by washing with soap & water. Remove stubborn contamination on hair by cutting with scissors or electric clippers. Promote sweating. Use survey meter to monitor progress of decontamination. Patient Management - Decontamination пЃ® Cease decontamination of skin and wounds: пЃ± пЃ± пЃ± пЃ® Contaminated thermal burns пЃ± пЃ± пЃ® When the area is less than twice background, or When there is no significant reduction between decon efforts, and Before intact skin becomes abraded. Gently rinse. Washing may increase severity of injury. Additional contamination will be removed when dressings are changed. Do not delay surgery or other necessary medical procedures or exams . . . residual contamination can be controlled. Treatment of Internal Contamination п‚§ Radionuclide-specific п‚§ Most effective when administered early п‚§ May need to act on preliminary information п‚§ NCRP Report No. 65, Management of Persons Accidentally Contaminated with Radionuclides Radionuclide Cesium-137 Iodine-125/131 Strontium-90 Americium-241/ Plutonium-239/ Cobalt-60 Treatment Prussian blue Potassium iodide Aluminum phosphate Ca- and Zn-DTPA Route Oral Oral Oral IV infusion, nebulizer Treatment of Large External Exposures п‚§ Estimating the severity of radiation injury is difficult. пЃ± пЃ± пЃ± п‚§ п‚§ Signs and symptoms (N,V,D,F): Rapid onset and greater severity indicate higher doses. Can be psychosomatic. CBC with absolute lymphocyte count Chromosomal analysis of lymphocytes (requires special lab) Treat symptomatically. Prevention and management of infection is the primary objective. пЃ± Hematopoietic growth factors, e.g., GM-CSF, G-CSF (24-48 hours) пЃ± Irradiated blood products пЃ± Antibiotics/reverse isolation пЃ± Electrolytes Seek the guidance of experts. пЃ± Radiation Emergency Assistance Center/Training Site (REAC/TS) пЃ± Medical Radiobiology Advisory Team (MRAT) Patient Management - Patient Transfer Transport injured, contaminated patient into or out of the emergency department: пЃ± пЃ± пЃ± пЃ± Cover clean gurney with two sheets. Lift patient onto clean gurney. Wrap sheets over patient. Roll gurney into emergency department or out of treatment room. Facility Recovery пЃ® пЃ® пЃ® Remove waste from the emergency department and triage area. Survey facility for contamination. Decontaminate as necessary: пЃ± пЃ± пЃ± пЃ® Normal cleaning routines (mop, strip waxed floors) typically very effective. Periodically reassess contamination levels. Replace furniture, floor tiles, etc., that cannot be adequately decontaminated. Decontamination goal: Less than twice normal background . . . higher levels may be acceptable. Special Considerations пЃ® пЃ® High radiation dose and trauma interact synergistically to increase mortality. For patients who received doses >100 rad: пЃ± пЃ± Close wounds, attend to any infection, look out for infections Wound care, burn care, and surgery should be done in the first 48 hours or delayed for 2 to 3 months Emergency Surgery Hematopoietic Recovery 24-48 Hours ~3 Months No Surgery Surgery Permitted After adequate hematopoietic recovery Other Considerations пЃ® пЃ® Victims may include the terrorist(s) (if this is a dirty bomb situation). In most cases, following universal precautions is all that is necessary to protect the staff. пЃ± пЃ± пЃ± пЃ± пЃ® Risk to caregivers, who would likely receive low doses, is very small. Hospital staff doses at Chernobyl <1 rem. 10 rem increases the risk of fatal cancer by ~1 percent. 25 rem increases the risk of severe hereditary effects by ~0.1 percent. Preplan who will be given radiation dosimeters Other Considerations пЃ® пЃ® Larger hospitals or large metropolitan areas should consider stocking decorporation agents. Dose rates to first responders 20 cm from patient with uniform surface contamination: пЃ± пЃ± пЃ® Cesium-137, 100 ВµCi/cm2 вЂ“ 1 rem/hr Cobalt-60, 100 ВµCi/cm2 вЂ“ 3.9 rem/hr Dose rates to surgeon standing 20 cm from patient with radioactive fragment (0.2 mm long, 0.2 mm radius, embedded 20 cm deep) пЃ± Cobalt-60, 1 Ci вЂ“ 2.5 rem/hr Psychological Casualties пЃ® Terrorist acts involving toxic agents (especially radiation) are perceived as very threatening. пЃ® Mass-casualty incidents caused by nuclear terrorism will create large numbers of worried people who may not be injured or contaminated. пЃ® Establish a center to provide psychological support to such people. пЃ® Set up a center in the hospital to provide psychological support for staff. Psychological Casualties пЃ® пЃ® пЃ® пЃ® Affected by fear of radiation and misunderstanding of consequences. Long-term psychological effects could arise hours or days after an incident. Counsel on acute and potential long-term physical and psychological effects. Psychological effects include: Anxiety disorders Depression Traumatic neurosis Post traumatic stress disorder Insomnia Acute stress disorder Psychological Casualties пЃ® пЃ® пЃ® пЃ® Provide psychological counseling to staff, victims, and their families. High-risk groups include emergency workers, children, mothers with small children, cleanup workers. Provide exposed patients with a вЂњsense of control of their health.вЂќ Resources: http://www.madison.va.gov/PTSD http://www.afrri.usuhs.mil/outreach/pdf/2edmmrchandbook.pdf Contaminated Corpses пЃ® пЃ® пЃ® пЃ® Disaster Mortuary Operational Response Teams (DMORT) Restrict autopsies of highly radioactive corpses. No embalming or cremation. Health physics assistance for autopsies: пЃ± пЃ± Use contamination control. Wear protective clothing. Key Points пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® Medical stabilization is the highest priority. Train/drill to ensure competence and confidence. Preplan to ensure adequate supplies and survey instruments are available. Universal precautions and decontaminating patients minimize exposure and contamination risk for staff. Early symptoms and their intensity are an indication of the severity of the radiation injury. The first 24 hours are the worst; then you will likely have many additional resources. Acknowledgments Prepared by the Medical Response Subcommittee of the National Health Physics Society Homeland Security Committee. Jerrold T. Bushberg, PhD, Chair Kenneth L. Miller, MS Marcia Hartman, MS Robert Derlet, MD Victoria Ritter, RN, MBA Edwin M. Leidholdt, Jr., PhD Consultants Fred A. Mettler, Jr., MD Niel Wald, MD William E. Dickerson, MD Appreciation to Linda Kroger, MS, who assisted in this effort. пѓЈ Health Physics Society Disclaimer: The information contained herein was current as of 13 Aug 2008 and is intended for educational purposes only. The authors and the Health Physics Society (HPS) do not assume any responsibility for the accuracy of the information presented herein. The authors and the HPS are not liable for any legal claims or damages that arise from acts or omissions that occur based on its use. The Health Physics Society is a nonprofit scientific professional organization whose mission is to promote the practice of radiation safety. Since its formation in 1956, the Society has grown to approximately 6,000 scientists, physicians, engineers, lawyers, and other professionals representing academia, industry, government, national laboratories, the Department of Defense, and other organizations. Society activities include encouraging research in radiation science, developing standards, and disseminating radiation safety information. Society members are involved in understanding, evaluating, and controlling the potential risks from radiation relative to the benefits. Official position statements are prepared and adopted in accordance with standard policies and procedures of the Society. The Society may be contacted at 1313 Dolley Madison Blvd., Suite 402, McLean, VA 22101; phone: 703-790-1745; fax: 703-790-2672; email: HPS@BurkInc.com.